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I.C. denying treatment after 20 years! help!
#1
My wife suffered a back injury at work in California, in January of 1987. She was awarded a small settlement and lifetime, as-required treatment of the injury in 1989. Over time, the injury got worse, eventually requiring (among other things), a spinal fusion and an intrathecal pump for the pain. She still requires monthly treatment and substantial medication to control the pain and suffering resulting from that injury. For nearly 20 years the WC insurance provider did not contest her treatment and fulfilled their responsibilities without issue; but a couple of years ago, they started questioning and/or delaying every single prescription or procedure (I believe they changed ownership). Now they are going to deny her claim entirely, and I hope that someone out there can offer us some guidance…

We moved to Florida some time ago, so they had my wife fly out to California earlier this year, (a very painful trip), where she was inspected by their doctor. Based on his 2 hour exam and a brief study of her voluminous previous medical history, their doctor concluded that "sitting on the grass at a concert" was the real cause of her suffering for the last 12 years, and that all treatment received since 1996 was in fact not related to the original injury, but was actually a result of the “injury” she suffered from "sitting on the grass at a concert" (including the B.A.K. fusion procedure and the implanting of an internal morphine pump a year later when the fusion had not helped…)

There is absolutely no medical evidence to suggest such a thing. There is one passing comment by an inspecting doctor from 12 years ago that she was in a lot of pain after attending the concert, which is true. Suffering from a flareup; she was sore before going to the concert; she even wore a back brace to the event! Ironically, their doctor’s first report made no mention of the concert, but rather tried to pin the blame on an “industrial accident” four years earlier. In 1992, my wife and several others at her workplace were tested for toxic exposure, but doctors determined that there was no evidence of it and the case was closed; in other words – there was no industrial accident… Their doctor hadn’t even read the reports well enough to realize this! So the IC lawyers wrote the doctor, stating how shocked they were by his conclusion, and asking had he properly considered the event in 1996 where my wife went to a concert? His next report made absolutely no mention of the “accident” in 1992, but now blamed EVERYTHING squarely upon "sitting on the grass at a concert".

The obvious conclusion is that they planned to find a reason to drop her, real or not…We have 20 years of doctor’s reports, X-Rays and MRIs on our side. They have the medically unsubstantiated opinion of a doctor who is being paid BY the insurance carrier. Since there is NO credible proof that 100% of her current pain is unrelated to the original injury, but is in fact all due to "sitting on the grass at a concert" 12 years ago, (even though no treating physicians at the time or since have suggested such a possibility), I didn’t think the process would go very far… I assumed we could simply hire an attorney who would have no problem making it go away, but as it turns out, that is not the case…Since we live in Florida now, we have had some major problems with the legal aspects of the situation – namely, we can't get a lawyer!

As I understand it, Workers Comp lawyers in California can legally only take compensation as a percentage of the settlement awarded to the injured worker - you can’t just “hire” an attorney. The lawyer from the original case back in 1987, Arthur D. Warren has retired. My wife’s case was settled in 1989, so there is no settlement for any new lawyer to get a percentage of, and no way for them to get paid! No one wants to talk to us… Even if we had the funds to just hire an attorney, we cannot do so legally!! I know that pro bono is a possibility, but we haven't found anyone interested as of yet…It seems insane to me, that the insurance carrier has hired a lawyer to take away my wife’s rights here, yet legally, we are essentially barred from getting representation to fight it! How can this possibly be????

The insurance carrier will completely stop covering my wife’s treatments in just a few weeks, leaving us with thousands of dollars a month in medical bills that we do not have. In preparation, she has tried to step down gradually on some of the meds over the last couple months so as not to go into total withdrawal; but it’s rough already and it’s going to get much worse….

I really thought that we’d be able to get some form of legal help – but we’ve had no luck. Trying to get clear guidance on this matter has proven very difficult from out of state. I have spoken at length with the WC Information and Assistance office, but as they cannot provide “legal advice”, they really haven’t been a lot of help. So, we will have to represent ourselves in court it seems; rarely a good idea, but I don’t know what else to do…

I am filing the request for an expedited hearing this week. Does anyone out there have any advice they can give us regarding expedited hearings and the appeals process, especially through self-representation? Has anyone else had their IC deny their claim so unjustly after so many years of accepted treatment like this?

Any shared experience, advice or assistance will be hugely appreciated!!!!

Thanks,

denspot
 
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#2
You really need to post over on this Cali specific forum. These guys have a wealth of information and it seems some of them really like putting the IC's in their place.

http://www.workcompforums.com/ca/iw/cate...m?catid=12
 
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#3
Your wife should contact the Information & Assistance Officer
http://www.dir.ca.gov/dwc/IandA.html
or the state Bar
http://www.calbar.ca.gov/state/calbar/ca...?cid=10174
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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